由小儿外科医生主导的伤口分类可提高准确性。
Pediatric surgeon-directed wound classification improves accuracy.
作者信息
Zens Tiffany J, Rusy Deborah A, Gosain Ankush
机构信息
Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American Family Children's Hospital, University of Wisconsin Hospital and Clinics Madison, Madison, Wisconsin.
American Family Children's Hospital, University of Wisconsin Hospital and Clinics Madison, Madison, Wisconsin; Division of Pediatric Anesthesia, Department of Anesthesia, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
出版信息
J Surg Res. 2016 Apr;201(2):432-9. doi: 10.1016/j.jss.2015.11.051. Epub 2015 Nov 30.
BACKGROUND
Surgical wound classification (SWC) communicates the degree of contamination in the surgical field and is used to stratify risk of surgical site infection and compare outcomes among centers. We hypothesized that by changing from nurse-directed to surgeon-directed SWC during a structured operative debrief, we will improve accuracy of documentation.
METHODS
An institutional review board-approved retrospective chart review was performed. Two time periods were defined: initially, SWC was determined and recorded by the circulating nurse (before debrief, June 2012-May 2013) and allowing 6 mo for adoption and education, we implemented a structured operative debriefing including surgeon-directed SWC (after debrief, January 2014-August 2014). Accuracy of SWC was determined for four commonly performed pediatric general surgery operations: inguinal hernia repair (clean), gastrostomy ± Nissen fundoplication (clean contaminated), appendectomy without perforation (contaminated), and appendectomy with perforation (dirty).
RESULTS
One hundred eighty-three cases before debrief and 142 cases after debrief met inclusion criteria. No differences between time periods were noted in regard to patient demographics, ASA class, or case mix. Accuracy of wound classification improved before debrief (42% versus 58.5%, P = 0.003). Before debrief, 26.8% of cases were overestimated or underestimated by more than one wound class, versus 3.5% of cases after debrief (P < 0.001). Interestingly, most after debrief contaminated cases were incorrectly classified as clean contaminated.
CONCLUSIONS
Implementation of a structured operative debrief including surgeon-directed SWC improves the percentage of correctly classified wounds and decreases the degree of inaccuracy in incorrectly classified cases. However, after implementation of the debriefing, we still observed a 41.5% rate of incorrect documentation, most notably in contaminated cases, indicating further education and process improvement is needed.
背景
手术伤口分类（SWC）传达手术区域的污染程度，用于分层手术部位感染风险并比较各中心的结果。我们假设，在结构化手术汇报期间从护士主导的SWC改为外科医生主导的SWC，将提高记录的准确性。
方法
进行了一项经机构审查委员会批准的回顾性病历审查。定义了两个时间段：最初，由巡回护士确定并记录SWC（汇报前，2012年6月至2013年5月），在经过6个月的采用和培训后，我们实施了包括外科医生主导的SWC的结构化手术汇报（汇报后，2014年1月至2014年8月）。针对四种常见的小儿普通外科手术确定SWC的准确性：腹股沟疝修补术（清洁）、胃造口术±尼森胃底折叠术（清洁-污染）、无穿孔阑尾切除术（污染）和穿孔阑尾切除术（污秽）。
结果
汇报前183例病例和汇报后142例病例符合纳入标准。在患者人口统计学、美国麻醉医师协会（ASA）分级或病例组合方面，各时间段之间未发现差异。汇报前伤口分类的准确性有所提高（42%对58.5%，P = 0.003）。汇报前，26.8%的病例被高估或低估超过一个伤口类别，而汇报后为3.5%的病例（P < 0.001）。有趣的是，汇报后大多数污染病例被错误分类为清洁-污染。
结论
实施包括外科医生主导的SWC的结构化手术汇报可提高正确分类伤口的百分比，并降低错误分类病例的不准确程度。然而，在实施汇报后，我们仍观察到41.5%的记录错误率，最明显的是在污染病例中，这表明需要进一步的教育和流程改进。
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